Rehabilitation interventions for vegetative and minimally conscious patients

Personalized music for cognitive and psychological symptom management during mechanical ventilation in critical care: A qualitative analysis

INTRODUCTION

Patients experience high symptom burden during critical care hospitalization and mechanical ventilation. Medications are of limited effectiveness and are associated with increased morbidity such as delirium and long-term cognitive and psychological impairments. Music-based interventions have been used for pain and anxiety management in critical care but remain understudied in terms of music selection and range of symptoms. This study aimed to describe the ways in which a diverse sample of critically ill adults used personalized music listening and their perceptions of the effects of music listening on symptom experience after critical injury.

METHODS

Semi-structured interviews (N = 14) of adult patients, families and friends who were provided with personalized music in an urban, academic, neurotrauma intensive care unit were collected and analyzed with grounded theory methodology. Open coding of transcripts, field notes and memos was performed using Atlas.ti.9.1. Recruitment and data collection were deemed complete once thematic saturation was achieved.

RESULTS

We identified 6 uses of personalized music listening in critical care: 1) Restoring consciousness; 2) Maintaining cognition; 3) Humanizing the hospital experience; 4) Providing a source of connection; 5) Improving psychological wellbeing; and 6) Resolving the problems of silence. Patients used music to address psychological experiences of loneliness, fear, confusion, and loss of control. Personalized music helped patients maintain their identity and process their trauma. Additional benefits of music included experiencing pleasure, hope, resilience, and feelings of normalcy. Patients disliked being sedated and used music to wake up. Findings also highlighted the problem of the lack of meaningful stimulation in critical care.

CONCLUSION

Critically injured adults used personalized music to achieve psychological and cognitive homeostasis during critical care hospitalization. These results can inform future studies designed to explore the use of music-based interventions to prevent and treat the cognitive and emotional morbidity of critical care.

Feasibility of overground exoskeleton gait training during inpatient rehabilitation after severe acquired brain injury

OBJECTIVE

To describe the safety, feasibility, and tolerability of overground exoskeleton gait training (OEGT) integrated into clinical practice for patients after severe acquired brain injury (ABI).

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

Eligible patients with severe ABI met the following criteria: age > 18, medically stable, met exoskeleton frame limitations, and a score of ≤ 3 on the motor function portion of the Coma Recovery Scale - Revised (CRS-R). Presence of consciousness disorder was not exclusionary.

DESIGN

Prospective observational study.

MAIN MEASURES

Outcomes examined safety (adverse events), feasibility (session count and barriers to session completion), and tolerability of OEGT (session metrics and heart rate).

RESULTS

Ten patients with ABI completed 10.4 ± 4.8 OEGT sessions with no adverse events. Barriers to session completion included clinical focus on prioritized interventions. Sessions [median up time = 17 minutes, (IQR: 7); walk time = 13 minutes, (IQR: 9); step count = 243, (IQR: 161); device assist = 74, (IQR: 28.0)] were primarily spent in Very Light to Light heart rate intensities [89%, (IQR: 42%) and 9%, (IQR: 33%), respectively].

CONCLUSION

OEGT incorporated into the rehabilitation plan of care during inpatient rehabilitation after severe ABI was observed to be safe, feasible, and tolerable. However, intentional steps must be taken to facilitate patient safety.

tDCS modulates effective connectivity during motor command following; a potential therapeutic target for disorders of consciousness

Transcranial direct current stimulation (tDCS) is attracting increasing interest as a potential therapeutic route for unresponsive patients with prolonged disorders of consciousness (PDOC). However, research to date has had mixed results. Here, we propose a new direction by directly addressing the mechanisms underlying lack of responsiveness in PDOC, and using these to define our targets and the success of our intervention in the healthy brain first. We report 2 experiments that assess whether tDCS to the primary motor cortex (M1-tDCS; Experiment 1) and the cerebellum (cb-tDCS; Experiment 2) administered at rest modulate thalamo-cortical coupling in a subsequent command following task typically used to clinically assess awareness. Both experiments use sham- and polarity-controlled, randomised, double-blind, crossover designs. In Experiment 1, 22 participants received anodal, cathodal, and sham M1-tDCS sessions while in the MRI scanner. A further 22 participants received the same protocol with cb-tDCS in Experiment 2. We used Dynamic Causal Modelling of fMRI to characterise the effects of tDCS on brain activity and dynamics during simple thumb movements in response to command. We found that M1-tDCS increased thalamic excitation and that Cathodal cb-tDCS increased excitatory coupling from thalamus to M1. All these changes were polarity specific. Combined, our experiments demonstrate that tDCS can successfully modulate long range thalamo-cortical dynamics during command following via targeting of cortical regions. This suggests that M1- and cb-tDCS may allow PDOC patients to overcome the motor deficits at the root of their reduced responsiveness, improving their rehabilitation options and quality of life as a result.

A consensus process to agree best practice for managing physical wellbeing in people with a prolonged disorder of consciousness

BACKGROUND

Current practice for physical wellbeing of people in a Prolonged Disorder of Consciousness (PDOC) is variable. A scoping literature review identified no agreed standard of care for physical management of those in a PDOC. This study addressed this deficit using a consensus process applied using nominal group technique.

AIM

The aims of this project were therefore to promote best practice for physical management in PDOC, by identifying consensus for: 1. a pathway of care and 2. current best practice recommendations.

DESIGN

A consensus process using nominal group technique.

SETTING

Representation from national, purposively selected, rehabilitation services assessing and managing people in a PDOC in the UK.

POPULATION

The population to whom the consensus process relates are people in a PDOC, requiring physical management.

METHODS

An initial meeting (1) with selected clinical experts from national centres was conducted to set terms of reference. A consensus meeting (2) using nominal group technique (n=33) then followed. Experts were initially asked to review systematic review findings reproduced as statements. Following systematic refinement they were then asked to vote on the importance and relevance of statements.

RESULTS

Following the nominal group process, 25 initial recommendations were refined to 19, which expressed the principles of physical management for people with a Prolonged Disorder of Consciousness. Statements are grouped into 'acute-care' (6-recommendations), 'post-acute care' (10-recommendations) and 'long-term care' (3-recommendations). Across the participants, agreement with the final recommendation statements ranged from 100-61% (n=33-20), 15 of the statements were supported by 85% or more experts (n=29). In addition, a clinical pathway of care, incorporating the recommendation principles was produced (agreement from 28 experts, 83%).

CONCLUSIONS

The recommendations provide a basis for standardising current practice. They provide a standard against which care and effectiveness can be evaluated. An accessible guideline document is planned for publication to enable implementation into practice, supported by online resources.

CLINICAL REHABILITATION IMPACT

Recommendations have been produced under the headings of 'acute care', 'post-acute care' and 'longterm care'. In addition, a pathway for provision of care interventions has been identified for the physical management of people in a prolonged disorder of consciousness.

Covert Speech Comprehension Predicts Recovery From Acute Unresponsive States

OBJECTIVE

Patients with traumatic brain injury who fail to obey commands after sedation-washout pose one of the most significant challenges for neurological prognostication. Reducing prognostic uncertainty will lead to more appropriate care decisions and ensure provision of limited rehabilitation resources to those most likely to benefit. Bedside markers of covert residual cognition, including speech comprehension, may reduce this uncertainty.

METHODS

We recruited 28 patients with acute traumatic brain injury who were 2 to 7 days sedation-free and failed to obey commands. Patients heard streams of isochronous monosyllabic words that built meaningful phrases and sentences while their brain activity via electroencephalography (EEG) was recorded. In healthy individuals, EEG activity only synchronizes with the rhythm of phrases and sentences when listeners consciously comprehend the speech. This approach therefore provides a measure of residual speech comprehension in unresponsive patients.

RESULTS

Seventeen and 16 patients were available for assessment with the Glasgow Outcome Scale Extended (GOSE) at 3 months and 6 months, respectively. Outcome significantly correlated with the strength of patients' acute cortical tracking of phrases and sentences (r > 0.6, p < 0.007), quantified by inter-trial phase coherence. Linear regressions revealed that the strength of this comprehension response (beta = 0.603, p = 0.006) significantly improved the accuracy of prognoses relative to clinical characteristics alone (eg, Glasgow Coma Scale [GCS], computed tomography [CT] grade).

INTERPRETATION

A simple, passive, auditory EEG protocol improves prognostic accuracy in a critical period of clinical decision making. Unlike other approaches to probing covert cognition for prognostication, this approach is entirely passive and therefore less susceptible to cognitive deficits, increasing the number of patients who may benefit. ANN NEUROL 2021;89:646-656.

Dysphagia in a persistently vegetative patient improved by orthodontic treatment of severe dental misalignment

INTRODUCTION

We describe the treatment of severe dysphagia in a patient left in a persistent vegetative state after an episode of hypoxic-ischemic encephalopathy following a traffic accident.

CASE REPORT

A 38-year-old man was in a persistent vegetative state since a traffic accident in 2005, which resulted in cardiopulmonary arrest and hypoxic-ischemic encephalopathy. His airway had been secured with a tracheostomy, and a gastric tube had been inserted; however, he continued to suffer from urinary tract infections, glossoptosis, and silent aspiration of saliva. Both the maxilla and mandible had very narrow dental arches, with the mandibular incisors exhibiting severe lingual inclination.

COURSE

We first corrected the dentition in the narrow maxillary arch, followed by the mandibular arch. As the dental alignment improved, tongue movements appeared during oral care, and endoscopy also revealed signs of an active saliva swallowing reflex.

DISCUSSION

The "training approach" generally used to treat severe dysphagia is usually impossible in persistently vegetative patients. In our patient, the tongue movements and saliva swallowing reflex appeared after we expanded the narrow dental arches, suggesting that an orthodontic approach can be effective in such cases. Our findings can be applied to similar cases of vegetative patients to facilitate better oral care and outcomes.

Early mobilization of a patient with acquired brain injury using a new standing aid, the Innowalk Pro. A single subject experimental design

BACKGROUND

Early mobilization is regarded as important in patients with severe acquired brain injury.

OBJECTIVE

To explore the feasibility, physical and physiological responses of using a new assistive, electric standing device, Innowalk Pro (IP), that passively moves the legs in an upright position.

DESIGN

A single-subject experimental design.

METHODS

A three-phase model (A₁-B-A₂) was chosen; A₁: baseline using a standing frame, B: an intervention using IP and A₂: withdrawal using a standing frame. Outcome measures: Patient's and assistive personnel's experiences with Likert scales, Modified Trunk Impairment Scale, Modified Ashworth Scale (MAS), Lidcombe Template (passive ankle dorsiflexion), duration of the training, blood pressure and heart rate.

RESULTS

A 40-year-old female, with subarachnoid haemorrhage, perceived training in the IP as more physically exhausting than training in a standing frame, influencing the training time. However, she preferred the IP over the standing frame. Trunk control did not improve, until the withdrawal phase. A small MAS reduction in ankle plantar flexors was maintained in the A₂-phase. The heart rate showed an ascending trend in A₁, and a non-significant descending trend in B- and A₂-phases. Blood pressure showed a flat trend line in A₁ and B-phases, and a descending trend in A₂.

CONCLUSION

The new IP was considered a feasible and motivating intervention. Heart rate tended to decrease during IP training, while the blood pressure remained stable. Further research is needed to evaluate whether the IP should be a preferable or a supplementary assistive device for early mobilization.Implications for rehabilitationA new electrical standing device, Innowalk Pro, which moves the legs in upright position, was found to be feasible in early mobilisation of a patient with severe brain injury.Trained physiotherapist and assistive personnel are recommended for safe training.Physiological responses like heart rate and blood pressure remained relatively stable when training in Innowalk Pro.We question whether the leg movements when standing in Innowalk Pro, may contribute to improvement in trunk control.

Predictors of Access to Rehabilitation in the Year Following Traumatic Brain Injury: A European Prospective and Multicenter Study

BACKGROUND

Although rehabilitation is beneficial for individuals with traumatic brain injury (TBI), a significant proportion of them do not receive adequate rehabilitation after acute care.

OBJECTIVE

Therefore, the goal of this prospective and multicenter study was to investigate predictors of access to rehabilitation in the year following injury in patients with TBI.

METHODS

Data from a large European study (CENTER-TBI), including TBIs of all severities between December 2014 and December 2017 were used (N = 4498 patients). Participants were dichotomized into those who had and those who did not have access to rehabilitation in the year following TBI. Potential predictors included sociodemographic factors, psychoactive substance use, preinjury medical history, injury-related factors, and factors related to medical care, complications, and discharge.

RESULTS

In the year following traumatic injury, 31.4% of patients received rehabilitation services. Access to rehabilitation was positively and significantly predicted by female sex (odds ratio [OR] = 1.50), increased number of years of education completed (OR = 1.05), living in Northern (OR = 1.62; reference: Western Europe) or Southern Europe (OR = 1.74), lower prehospital Glasgow Coma Scale score (OR = 1.03), higher Injury Severity Score (OR = 1.01), intracranial (OR = 1.33) and extracranial (OR = 1.99) surgery, and extracranial complication (OR = 1.75). On contrast, significant negative predictors were lack of preinjury employment (OR = 0.80), living in Central and Eastern Europe (OR = 0.42), and admission to hospital ward (OR = 0.47; reference: admission to intensive care unit) or direct discharge from emergency room (OR = 0.24).

CONCLUSIONS

Based on these findings, there is an urgent need to implement national and international guidelines and strategies for access to rehabilitation after TBI.

Effect of repetitive transcranial magnetic stimulation on the ascending reticular activating system in a patient with disorder of consciousness: a case report

Background

We report on a stroke patient with disorder of consciousness (DOC) who underwent repetitive transcranial magnetic stimulation (rTMS) and showed recovery of an injured upper ascending reticular activating system (ARAS) injury, which was demonstrated by using serial diffusion tensor tractography (DTT).

Case presentation

A 45-year-old male patient was diagnosed as subarachnoid and intracerebral hemorrhages in the left fronto-parieto-temporal lobes. At 5 months after onset, the patient exhibited a persistent vegetative state, with a Coma Recovery Scale-Revised (CRS-R) score of 4. He underwent comprehensive rehabilitative therapy that included drugs for recovery of impaired consciousness and rTMS of the right dorsolateral prefrontal lobe. He recovered to a minimally conscious state (CRS-R: 13) at 7 months after onset and was transferred to a local rehabilitation hospital where he underwent similar rehabilitation but without rTMS. At 9 months after onset, his CRS-R score remained at 13. He was then readmitted to our hospital and underwent rehabilitation with rTMS until 10 months after onset. His CRS-R remained at 13, but his higher cognition had improved. The tract volume (TV) of the neural tract in the right prefrontal lobe in the upper ARAS on the 7-month DTT was higher than that on the 5-month DTT. However, compared to the 7-month DTT, the right prefrontal lobe TV was lower on the 9-month DTT. On the 10-month DTT, the TV of that neural tract had again increased.

Conclusions

Increases in neural TV in the right prefrontal lobe of the upper ARAS that were associated with the periods of rTMS application were demonstrated in a stroke patient with DOC.

Early Intensive Rehabilitation for Patients with Traumatic Brain Injury: A Prospective Pilot Trial

OBJECTIVE

To investigate the effects of early intensive rehabilitation management on the recovery of motor function and activities of daily living in patients with moderate traumatic brain injury.

METHODS

Eighty-seven patients (age range, 18-65 years) with traumatic brain injury that met the enrollment criteria were randomly divided into 2 groups. Group 1 received early and high-intensity rehabilitation management (from 7 days after injury, 7 d/wk, 4 times/d, 1 h/session) for 4 weeks; group 2 received ordinary rehabilitation (from 14 days after injury, 5 d/wk, 2 times/d, 1 h/session) for 4 weeks. The Fugl-Meyer Assessment (FMA, motor function) and Barthel Index (BI) were used to assess the daily living functional state before treatment, 3 months after injury, and 6 months after injury. The Glasgow Coma Scale (GCS) was used to assess outcomes 6 months after injury.

RESULTS

Three months after rehabilitation, the FMA (motor function) score was significantly higher in the early intensive intervention group versus the control group (59.83 ± 11.87 vs. 44.56 ± 8.32, respectively; P < 0.05); no significant between-group differences were found in the GCS score or BI score (P > 0.05). Six months after rehabilitation, the FMA score and BI score were significantly higher in the early intensive intervention group versus the control group (FMA: 73.18 ± 16.55 vs. 57.86 ± 10.67, P < 0.01; BI: 87.17 ± 13.85 vs. 60.68 ± 11.98, P < 0.01, respectively). The GCS score was higher in the early intensive intervention group versus the control group (4.24 ± 0.91 vs. 3.43 ± 0.88, P < 0.05, respectively) 6 months after injury.

CONCLUSIONS

Early intensive rehabilitation management might be more beneficial for neurologic function and activities of daily living in patients with moderate traumatic brain injury.

Development of muscle contractures and spasticity during subacute rehabilitation after severe acquired brain injury: a prospective cohort study

Objective: This study investigated the development of contractures, passive stiffness, and spasticity in the ankle joint in patients with severe acquired brain injury (ABI) from admission to rehabilitation unit until 1-year post-injury compared to healthy controls. Design: An observational longitudinal cohort study Methods and procedures: Nineteen patients (26 affected ankle joints) with severe ABI >17 years old and with paresis of a lower limb admitted to sub-acute neurorehabilitation were compared to 14 healthy controls (28 ankle joints). Passive and reflex-mediated ankle joint stiffness was obtained measuring torque, range of motion, velocity and acceleration of the ankle movements. Data was collected at inclusion, after 4-5 weeks, after 8-9 weeks and at 1-year follow-up. Outcomes and results: At admittance to rehabilitation range of motion and stiffness was significantly lower compared to controls. Range of motion decreased by one degree in three weeks and passive ankle joint stiffness increased significantly by 1% per week. More patients than controls had no stretch reflex. Conclusion: Patients with severe ABI show reduced mobility and increased passive stiffness despite less spasticity in the ankle joint compared to healthy controls. Research and clinical practice should therefore focus intensively on the prevention of contractures in the ankle joint. ISRCTN17910097.

Brugada syndrome and the story of Dave

Brugada syndrome (BrS) is a little known genetic condition that causes severe disturbances in cardiac rhythm and may result in sudden unexpected cardiac death in an apparently healthy person. The heart structure is typically normal but there are problems with electrical activity. The syndrome is named after Spanish brothers who are cardiologists, Pedro and Josep Brugada. BrS is the major cause of sudden unexplained death syndrome (SUDS), also known as sudden arrhythmic death syndrome (SADS). Following a description of the syndrome, including its prevalence and incidence, how it is diagnosed and how it can be treated, we consider those who survive a cardiac arrest and what problems they may face. Most publications focus on the medical aspects of BrS but, of course, cardiac arrest can result in hypoxic brain damage. We conclude with the story of Dave, a 25-year-old man diagnosed with BrS following a nose bleed and subsequent cardiac arrest. He was left with a visual impairment, dystonia, hypersensitivity, and language and cognitive dysfunction. We look at Dave's strengths and weaknesses, his response to offered treatment, and his consequent improvement. We stress the contributions from members of the multidisciplinary team and offer suggestions for the rehabilitation of other survivors of BrS.

Effectiveness of a Very Early Stepping Verticalization Protocol in Severe Acquired Brain Injured Patients: A Randomized Pilot Study in ICU

BACKGROUND AND OBJECTIVE

Verticalization was reported to improve the level of arousal and awareness in patients with severe acquired brain injury (ABI) and to be safe in ICU. We evaluated the effectiveness of a very early stepping verticalization protocol on their functional and neurological outcome.

METHODS

Consecutive patients with Vegetative State or Minimally Conscious State were enrolled in ICU on the third day after an ABI. They were randomized to undergo conventional physiotherapy alone or associated to fifteen 30-minute sessions of verticalization, using a tilt table with robotic stepping device. Once stabilized, patients were transferred to our Neurorehabilitation unit for an individualized treatment. Outcome measures (Glasgow Coma Scale, Coma Recovery Scale revised -CRSr-, Disability Rating Scale-DRS- and Levels of Cognitive Functioning) were assessed on the third day from the injury (T0), at ICU discharge (T1) and at Rehab discharge (T2). Between- and within-group comparisons were performed by the Mann-Whitney U test and Wilcoxon signed-rank test, respectively.

RESULTS

Of the 40 patients enrolled, 31 completed the study without adverse events (15 in the verticalization group and 16 in the conventional physiotherapy). Early verticalization started 12.4±7.3 (mean±SD) days after ABI. The length of stay in ICU was longer for the verticalization group (38.8 ± 15.7 vs 25.1 ± 11.2 days, p = 0.01), while the total length of stay (ICU+Neurorehabilitation) was not significantly different (153.2 ± 59.6 vs 134.0 ± 61.0 days, p = 0.41). All outcome measures significantly improved in both groups after the overall period (T2 vs T0, p<0.001 all), as well as after ICU stay (T1 vs T0, p<0.004 all) and after Neurorehabilitation (T2 vs T1, p<0.004 all). The improvement was significantly better in the experimental group for CRSr (T2-T0 p = 0.033, T1-T0 p = 0.006) and (borderline) for DRS (T2-T0 p = 0.040, T1-T0 p = 0.058).

CONCLUSIONS

A stepping verticalization protocol, started since the acute stages, improves the short-term and long-term functional and neurological outcome of ABI patients.

TRIAL REGISTRATION

clinicaltrials.gov NCT02828371.

Assistive technology to help persons in a minimally conscious state develop responding and stimulation control: Performance assessment and social rating

BACKGROUND

Post-coma persons in a minimally conscious state (MCS) and with extensive motor impairment and lack of speech tend to be passive and isolated.

OBJECTIVE

This study aimed to (a) further assess a technology-aided approach for fostering MCS participants' responding and stimulation control and (b) carry out a social validation check about the approach.

METHODS

Eight MCS participants were exposed to the aforementioned approach according to an ABAB design. The technology included optic, pressure or touch microswitches to monitor eyelid, hand or finger responses and a computer system that allowed those responses to produce brief periods of positive stimulation during the B (intervention) phases of the study. Eighty-four university psychology students and 42 care and health professionals were involved in the social validation check.

RESULTS

The MCS participants showed clear increases in their response frequencies, thus producing increases in their levels of environmental stimulation input, during the B phases of the study. The students and care and health professionals involved in the social validation check rated the technology-aided approach more positively than a control condition in which stimulation was automatically presented to the participants.

CONCLUSIONS

A technology-aided approach to foster responding and stimulation control in MCS persons may be effective and socially desirable.

Recovery of consciousness and an injured ascending reticular activating system in a patient who survived cardiac arrest: A case report

We report on a patient who survived cardiac arrest and showed recovery of consciousness and an injured ARAS at the early stage of hypoxic-ischemic brain injury (HI- BI) for 3 weeks, which was demonstrated by diffusion tensor tractography (DTT).A 52-year-old male patient who had suffered cardiac arrest caused by acute coronary syndrome was resuscitated immediately by a layman and paramedics for ∼25 minutes. He was then transferred immediately to the emergency room of a local medical center. When starting rehabilitation at 2 weeks after onset, his consciousness was impaired, with a Glasgow Coma Scale (GCS) score of 8 and Coma Recovery Scale-Revised (GRS-R) score of 8. He underwent comprehensive rehabilitative therapy, including drugs for recovery of consciousness. He recovered well and rapidly so that his consciousness had recovered to full scores in terms of GCS:15 and GRS-R:23 at 5 weeks after onset.The left lower dorsal and right lower ventral ARAS had become thicker on 5-week DTT compared with 2-week DTT (Fig. 1B). Regarding the change of neural connectivity of the thalamic ILN, increased neural connectivity to the basal forebrain and prefrontal cortex was observed in both hemispheres on 5-week DTT compared with 2-week DTT.Recovery of an injured ARAS was demonstrated in a patient who survived cardiac arrest and his consciousness showed rapid and good recovery for 3 weeks at the early stage of HI-BI.

Tilt Table Therapies for Patients with Severe Disorders of Consciousness: A Randomized, Controlled Trial

One major aim of the neurological rehabilitation of patients with severe disorders of consciousness (DOC) is to enhance patients' arousal and ability to communicate. Mobilization into a standing position by means of a tilt table has been shown to improve their arousal and awareness. However, due to the frequent occurrence of syncopes on a tilt table, it is easier to accomplish verticalization using a tilt table with an integrated stepping device. The objective of this randomized controlled clinical trial was to evaluate the effectiveness of a tilt table therapy with or without an integrated stepping device on the level of consciousness. A total of 50 participants in vegetative or minimally conscious states 4 weeks to 6 month after injury were treated with verticalization during this randomized controlled trial. Interventions involved ten 1-hour sessions of the specific treatment over a 3-week period. Blinded assessors made measurements before and after the intervention period, as well as after a 3-week follow-up period. The coma recovery scale-revised (CRS-R) showed an improvement by a median of 2 points for the group receiving tilt table with integrated stepping (Erigo). The rate of recovery of the group receiving the conventional tilt table therapy significantly increased by 5 points during treatment and by an additional 2 points during the 3-week follow-up period. Changes in spasticity did not significantly differ between the two intervention groups. Compared to the conventional tilt table, the tilt table with integrated stepping device failed to have any additional benefit for DOC patients. Verticalization itself seems to be beneficial though and should be administered to patients in DOC in early rehabilitation. Trial Registration: Current Controlled Trials Ltd (www.controlled-trials.com), identifier number ISRCTN72853718.

Physiotherapy for vegetative and minimally conscious state patients: family perceptions and experiences

PURPOSE

To examine family perceptions of physiotherapy provided to relatives in vegetative or minimally conscious states.

METHOD

Secondary thematic analysis of 65 in-depth narrative interviews with family members of people in vegetative or minimally conscious states.

RESULTS

Families place great significance on physiotherapy in relation to six dimensions: "Caring for the person", "Maximising comfort", "Helping maintain health/life", "Facilitating progress", "Identifying or stimulating consciousness" and "Indicating potential for meaningful recovery". They can have high expectations of what physiotherapy may deliver but also, at times, express concerns about physiotherapy's potential to cause pain or distress, or even constitute a form of torture if they believe there is no hope for "meaningful" recovery.

CONCLUSION

Physiotherapists can make an important contribution to supporting this patient group and their families but it is vital to recognise that family understandings of physiotherapy may differ significantly from those of physiotherapists. Both the delivery and the withdrawal of physiotherapy is highly symbolic and can convey (inadvertent) messages to people about their relative's current and future state. A genuine two-way dialogue between practitioners and families about the aims of physiotherapeutic interventions, potential outcomes and patients' best interests is critical to providing a good service and establishing positive relationships and appropriate treatment.

IMPLICATIONS FOR REHABILITATION

Families of people in PVS or MCS consider physiotherapy as a vital part of good care. Clear communication is critical if therapeutic input is withdrawn or reduced. The purpose of physiotherapy interventions can be misinterpreted by family members. Physiotherapists need to clarify what physiotherapy can, and cannot, achieve. Families can find some interventions distressing to witness--explaining to families what interventions involve, what they can expect to see (and hear) may be helpful. Physiotherapists and families can attribute different meanings to physiotherapy. Physiotherapists need to identify how families view interventions and modify their explanations accordingly to enhance information sharing.

Quantitative EEG analysis in minimally conscious state patients during postural changes

Mobilization and postural changes of patients with cognitive impairment are standard clinical practices useful for both psychic and physical rehabilitation process. During this process, several physiological signals, such as Electroen-cephalogram (EEG), Electrocardiogram (ECG), Photopletysmography (PPG), Respiration activity (RESP), Electrodermal activity (EDA), are monitored and processed. In this paper we investigated how quantitative EEG (qEEG) changes with postural modifications in minimally conscious state patients. This study is quite novel and no similar experimental data can be found in the current literature, therefore, although results are very encouraging, a quantitative analysis of the cortical area activated in such postural changes still needs to be deeply investigated. More specifically, this paper shows EEG power spectra and brain symmetry index modifications during a verticalization procedure, from 0 to 60 degrees, of three patients in Minimally Consciousness State (MCS) with focused region of impairment. Experimental results show a significant increase of the power in β band (12 - 30 Hz), commonly associated to human alertness process, thus suggesting that mobilization and postural changes can have beneficial effects in MCS patients.

Promoting the use of personally relevant stimuli for investigating patients with disorders of consciousness

Sensory stimuli are used to evaluate and to restore cognitive functions and consciousness in patients with a disorder of consciousness (DOC) following a severe brain injury. Although sophisticated protocols can help assessing higher order cognitive functions and awareness, one major drawback is their lack of sensitivity. The aim of the present review is to show that stimulus selection is crucial for an accurate evaluation of the state of patients with disorders of consciousness as it determines the levels of processing that the patient can have with stimulation from his/her environment. The probability to observe a behavioral response or a cerebral response is increased when her/his personal history and/or her/his personal preferences are taken into account. We show that personally relevant stimuli (i.e., with emotional, autobiographical, or self-related characteristics) are associated with clearer signs of perception than are irrelevant stimuli in patients with DOC. Among personally relevant stimuli, music appears to be a promising clinical tool as it boosts perception and cognition in patients with DOC and could also serve as a prognostic tool. We suggest that the effect of music on cerebral processes in patients might reflect the music's capacity to act both on the external and internal neural networks supporting consciousness.

Facilitating patients with disorders of consciousness to sit without trunk support: a qualitative study

AIMS AND OBJECTIVES

This study aimed to clarify why and how clinical nurses facilitate sitting without trunk support among patients with disorders of consciousness.

BACKGROUND

Recent attention has focused on encouraging patients with disorders of consciousness to sit without trunk support, but no reports describe this intervention among patients with poor awareness and physical disuse.

DESIGN

Qualitative research design.

METHODS

We enrolled five clinical nurses with interventional experience in rehabilitating patients with disorders of consciousness to sit without trunk support. Participant observation and semi-structured interviews were used to collect data. The data were analysed by text-mining method.

RESULTS

Three reasons for nursing in the sitting position were identified: to raise the patient's body to assess the recovery of activities of daily living, to adjust their circadian rhythm and encourage the will to sit, and to make it easier to breathe. Five practices were identified: moving the patient to the prone position to sit in safety and comfort, developing postural stability by improving the flexibility of the lower limbs, improving the flexibility of the hip joints, developing trunk balance and encouraging hand use for stability, and ensuring safety by terminating the sitting practice when symptoms of respiratory failure, heart failure, or excessive tiredness developed.

CONCLUSIONS

The rationale for nursing patients with disorders of consciousness to sit without trunk support was to establish a foundation for independent living. This was achieved by preparing patient's disused body for activity by improving the flexibility of hip joint in the prone position. This represents a new intervention for patients with disorders of consciousness that could facilitate independent living.

RELEVANCE TO CLINICAL PRACTICE

This study provides empirical and practical evidence from nurses who perform novel clinical interventions that specifically promote independent living. Further accumulation of quantitative clinical results and physiological verification are required.

Supporting self-managed leisure engagement and communication in post-coma persons with multiple disabilities

Post-coma persons affected by extensive motor impairment and lack of speech, with or without disorders of consciousness, need special support to manage leisure engagement and communication. These two studies extended research efforts aimed at assessing basic technology-aided programs to provide such support. Specifically, Study I assessed a program for promoting independent stimulation choice in four post-coma persons who combined motor and speech disabilities with disorders of consciousness (i.e., were rated between the minimally conscious state and the emergence from such state). Study II assessed a program for promoting independent television operation and basic communication in three post-coma participants who, contrary to those involved in Study I, did not have disorders of consciousness (i.e., had emerged from a minimally conscious state). The results of the studies were largely positive with substantial levels of independent stimulation choice and access for the participants of Study I and independent television operation and communication for the participants of Study II. The results were analyzed in relation to previous data in the area and in terms of their implications for daily contexts dealing with these persons.

Early rehabilitation of patients with severe acquired brain injury: strategies to promote participation

PURPOSE

The aim of this study was to explore the experiences of professional specialists in early rehabilitation who face demanding pedagogical challenges in facilitating and promoting participation of the severe acquired brain injury patient.

METHOD

In a qualitative study, using phenomenological philosophy and thinking, the experiences of specialist professional experts were investigated. Data were generated in five individual interviews and one focus-group interview. The interview questions were grounded in a preliminary field study. In a four-step phenomenological analysis, empirical themes were identified, using the computer program N-Vivo10; they were structured and organized, and the results were theoretically stated and supported.

RESULTS

Important practice knowledge emerged in this study that led to the proposal of a determined, client-centred approach when facilitating the promotion of severe acquired brain injury patients' participation in early rehabilitation. Four factors are important in this approach: (i) gain contact, (ii) register responses, (iii) intentional interaction, (iv) partial participation. Together they constitute the elements in a proposal for a new model: the GRIP model.

CONCLUSION

The four factors that shape the GRIP model can enrich neurorehabilitation services and support professional experts in early rehabilitation interventions with severe acquired brain injury patients regaining participation and functioning in everyday life.

Clinical management of the minimally conscious state

The minimally conscious state (MCS) was defined as a disorder of consciousness (DoC) distinct from the vegetative state more than a decade ago. While this condition has become widely recognized, there are still no guidelines to steer the approach to assessment and treatment. The development of evidence-based practice guidelines for MCS has been hampered by ambiguity around the concept of consciousness, the lack of accurate methods of assessment, and the dearth of well-designed clinical trials. This chapter provides a critical review of existing assessment procedures, critically reviews available treatment options and identifies knowledge gaps. We close with practice-based recommendations for a rational approach to clinical management of this challenging population.

Technology-aided programs for post-coma patients emerged from or in a minimally conscious state

Post-coma persons in a minimally conscious state (MCS) or emerged/emerging from such state (E-MCS), who are affected by extensive motor impairment and lack of speech, may develop an active role and interact with their environment with the help of technology-aided intervention programs. Although a number of studies have been conducted in this area during the last few years, new evidence about the efficacy of those programs is warranted. These three studies were an effort in that direction. Study I assessed a technology-aided program to enable six MCS participants to access preferred environmental stimulation independently. Studies II and III assessed technology-aided programs to enable six E-MCS participants to make choices. In Study II, three of those participants were led to choose among leisure and social stimuli, and caregiver interventions automatically presented to them. In Study III, the remaining three participants were led to choose (a) among general stimulus/intervention options (e.g., songs, video-recordings of family members, and caregiver interventions); and then (b) among variants of those options. The results of all three studies were largely positive with substantial increases of independent stimulation access for the participants of Study I and independent choice behavior for the participants of Studies II and III. The results were analyzed in relation to previous data and in terms of their implications for daily contexts working with MCS and E-MCS persons affected by multiple disabilities.

Microswitch-aided programs with contingent stimulation versus general stimulation programs for post-coma persons with multiple disabilities

OBJECTIVE

Assessing the impact of microswitch-aided programs with contingent stimulation on response engagement (Study I) and post-session alertness (Study II) of post-coma participants with multiple disabilities.

METHOD

Study I included three participants whose scores on the Coma Recovery Scale-Revised (CRS-R) were 11 or 13. Study II included three participants whose CRS-R scores were 19, 13, and 14. In both studies, the participants received sessions with contingent stimulation (i.e., sessions in which activation of a microswitch with an eyelid or hand response produced 15 s of preferred stimulation) and sessions with general, non-contingent stimulation (i.e., stimulation lasted throughout the sessions).

RESULTS

Study I showed an increase in response engagement/frequencies only during the contingent stimulation sessions. Study II showed that the participants' level of vigilance after those sessions was higher than after non-contingent stimulation sessions.

CONCLUSION

Microswitch-aided programs with contingent stimulation would be more beneficial than programs with general/non-contingent stimulation.

Occupation and communication programs for post-coma persons with or without consciousness disorders who show extensive motor impairment and lack of speech

These two studies were aimed at extending the assessment of technology-aided programs for post-coma persons with extensive motor impairment and lack of speech. Specifically, Study I assessed a new program arrangement, in which stimulation access and caregiver attention could be obtained with variations of the same response (i.e., single- versus double-hand closure) by three participants who were diagnosed at the upper level of the minimally conscious state at the start of the study. Study II was aimed at enabling two persons who had emerged from a minimally conscious state to engage in leisure activities, listen to audio-recordings of family members, and send and receive messages. The responses selected for these participants were hand pressure and eyelid closure, respectively. The results of both studies were positive. The participants of Study I increased their responding to increase their stimulation input and caregiver interaction. The participants of Study II managed to successfully select all the options the program included (i.e., the leisure options, as well as the family and communication options). General implications of the programs and the related technology packages for intervention with post-coma persons with multiple disabilities are discussed.

Technology-based intervention programs to promote stimulation control and communication in post-coma persons with different levels of disability

Post-coma persons in a minimally conscious state and with extensive motor impairment or emerging/emerged from such a state, but affected by lack of speech and motor impairment, tend to be passive and isolated. A way to help them develop functional responding to control environmental events and communication involves the use of intervention programs relying on assistive technology. This paper provides an overview of technology-based intervention programs for enabling the participants to (a) access brief periods of stimulation through one or two microswitches, (b) pursue stimulation and social contact through the combination of a microswitch and a sensor connected to a speech generating device (SGD) or through two SGD-related sensors, (c) control stimulation options through computer or radio systems and a microswitch, (d) communicate through modified messaging or telephone systems operated via microswitch, and (e) control combinations of leisure and communication options through computer systems operated via microswitch. Twenty-six studies, involving a total of 52 participants, were included in this paper. The intervention programs were carried out using single-subject methodology, and their outcomes were generally considered positive from the standpoint of the participants and their context. Practical implications of the programs are discussed.

Clinical and neuropsychological long-term outcomes after late recovery of responsiveness: a case series

OBJECTIVE

To report clinical conditions and neuropsychological functioning of patients with late recovery of responsiveness at least 5 years after injury.

DESIGN

Patient series.

SETTING

Patients discharged from an inpatient rehabilitation unit.

PARTICIPANTS

Patients (N=13) who recovered from a vegetative state 1 year after severe traumatic brain injury or 6 months after nontraumatic brain injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Coma Recovery Scale-Revised, Disability Rating Scale, and FIM. For patients who recovered full consciousness, neuropsychological tests specifically adapted for patients with very severe disabilities were used.

RESULTS

After regaining responsiveness, 2 patients died because of severe clinical complications. Among the remaining 11 patients, 5 were still in a minimally conscious state at their last assessment, but 4 of them had recovered some complex behavioral responses to the environment (eg, they could follow simple commands, albeit inconsistently). Six patients had emerged from a minimally conscious state at the last evaluation. Severe functional disability was present in both patients who were conscious and patients who were minimally conscious. No patient was autonomous in common daily life activities or in transfers. All patients who were conscious showed variable cognitive impairments, and some of them also developed behavioral and psychological symptoms. However, such disturbances did not impede the patients' interaction with relatives and caregivers.

CONCLUSIONS

This study provides systematic data about the course of the disease in a cohort of patients that was previously considered as exceptional. Patients with late recovery show a variable degree of functional recovery, although they experience marked residual motor and cognitive disabilities. The present findings contribute to enhance the understanding of the course of the disease in patients with late recovery and might help clinicians optimize the levels of care and provide the patients' families with correct information.

Specialized early treatment for persons with disorders of consciousness: program components and outcomes

OBJECTIVES

To describe a specialized early treatment program for persons with disorders of consciousness (DOC) that includes family education; to identify rates of secondary conditions, imaging used, and selected interventions; and to evaluate outcomes.

DESIGN

A single-center, retrospective, pre-post design using electronic medical record data.

SETTING

A Commission on Accreditation of Rehabilitation Facilities-accredited, long-term acute care hospital that provides acute medical and inpatient rehabilitation levels of care for people with catastrophic injuries.

PARTICIPANTS

Persons (N=210) aged 14 to 69 years with DOC of primarily traumatic etiology admitted at a mean ± SD of 41.0 ± 27.2 days postinjury; 2% were in coma, 41% were in the vegetative state, and 57% were in the minimally conscious state.

INTERVENTIONS

An acute medical level of care with ≥90 minutes of daily interdisciplinary rehabilitation and didactic and hands-on caretaking education for families.

MAIN OUTCOME MEASURES

Coma Recovery Scale-Revised, Modified Ashworth Scale, and discharge disposition.

RESULTS

Program admission medical acuity included dysautonomia (15%), airway modifications (79%), infections (eg, pneumonia, 16%; urinary tract infection, 14%; blood, 11%), deep vein thrombosis (17%), pressure ulcers (14%), and marked hypertonia (30% in each limb). There were 168 program interruptions (ie, 139 surgeries, 29 nonsurgical intensive care unit transfers). Mean length of stay ± SD was 39.1 ± 29.4 days (range, 6-204d). Patients showed improved consciousness and respiratory function and reduced presence or severity of pressure ulcers and upper extremity hypertonia. At discharge, 54% showed sufficient emergence from a minimally conscious state to transition to mainstream inpatient rehabilitation, and 29% did not emerge but were discharged home to family with ongoing programmatic support; only 13% did not emerge and were institutionalized.

CONCLUSIONS

Persons with DOC resulting primarily from a traumatic etiology who receive specialized early treatment that includes acute medical care and ≥90 minutes of daily rehabilitation are likely to show improved consciousness and body function; more than half may transition to mainstream inpatient rehabilitation. Families who receive comprehensive education and hands-on training with ongoing follow-up support may be twice as likely to provide care for medically stable persons with DOC in their homes versus nursing facility placement.

Early poststroke rehabilitation using a robotic tilt-table stepper and functional electrical stimulation

Background. Stroke frequently leaves survivors with hemiparesis. To prevent persistent deficits, rehabilitation may be more effective if started early. Early training is often limited because of orthostatic reactions. Tilt-table stepping robots and functional electrical stimulation (FES) may prevent these reactions. Objective. This controlled convenience sample study compares safety and feasibility of robotic tilt-table training plus FES (ROBO-FES) and robotic tilt-table training (ROBO) against tilt-table training alone (control). A preliminary assessment of efficacy is performed. Methods. Hemiparetic ischemic stroke survivors (age 58.3 ± 1.2 years, 4.6 ± 1.2 days after stroke) were assigned to 30 days of ROBO-FES (n = 38), ROBO (n = 35), or control (n = 31) in addition to conventional physical therapy. Impedance cardiography and transcranial doppler sonography were performed before, during, and after training. Hemiparesis was assessed using the British Medical Research Council (MRC) strength scale. Results. No serious adverse events occurred; 8 patients in the tilt-table group prematurely quit the study because of orthostatic reactions. Blood pressure and CBFV dipped <10% during robot training. In 52% of controls mean arterial pressure decreased by ≥20%. ROBO-FES increased leg strength by 1.97 ± 0.88 points, ROBO by 1.50 ± 0.85 more than control (1.03 ± 0.61, P < 0.05). CBFV increased in both robotic groups more than in controls (P < 0.05). Conclusions. Robotic tilt-table exercise with or without FES is safe and may be more effective in improving leg strength and cerebral blood flow than tilt table alone.

Intensive physiotherapy for vegetative and minimally conscious state patients: a retrospective audit and analysis of therapy intervention

PURPOSE

To analyse physiotherapy interventions and evaluate their effectiveness in the prevention and management of contracture with patients admitted in either vegetative or minimally conscious state in a UK Inpatient Regional Acquired Brain Injury Rehabilitation Service.

METHOD

Retrospective audit of dependency levels and physiotherapy interventions in ten vegetative or minimally conscious state patients admitted over a 3-year period (2006-2009). Admission and discharge patient dependency status, Wessex Head Injury Matrix data and passive range of movement measurements on admission and discharge from physiotherapy were recorded.

RESULTS

All patients presented with hypertonicity including contractures and all initially received a manual stretching/passive movement programme. Casting/splinting was employed in 8 cases and 7 received botulinum toxin injections. Standing regimes were initiated for 8 patients. No patient emerged out of either vegetative or minimally conscious state. Although they remained fully dependent for care needs, carer burden was reduced and all patients were able sustain a seating regimen. No minimal clinically important difference was observed in 85 out of 120 joint ranges measured (70.8%). Positive outcomes were observed in only 14 joints (11.7%) and negative outcomes in 21 joints (17.5%).

CONCLUSION

At present, there is a paucity of evidence regarding physiotherapy efficacy to inform the management of patients in vegetative or minimally conscious state. Clearer agreed definitions of clinically important difference in passive range of movement are required to allow better interpretation of outcomes. Interventions should be aimed at minimising carer burden and developing individualised disability management programmes. Further research documenting the long-term outcomes in such patients is warranted.

A learning assessment procedure as a test supplement for monitoring progress with two post-coma persons with a diagnosis of vegetative state

OBJECTIVE

Evaluating a learning assessment procedure for monitoring progress with two post-coma adults with a diagnosis of vegetative state.

METHOD

ABABCBCB and ABABCB designs were used for the two participants, with A representing baseline, B intervention and C control conditions. Participants' activation of an optic microswitch by eyelid closure produced stimulation during B phases.

RESULTS

One participant increased responding during B phases and decreased it during the C condition, suggesting a non-reflective minimal level of consciousness. She showed P300 and mismatch negativity responses and scored at the vegetative level on the Coma Recovery Scale-Revised (CRS-R). The other participant increased responding during the initial B phases without decline during the first (viable) part of the C condition, suggesting a pre-conscious level. He showed indistinct P300 and mismatch negativity responses and vegetative-level scores on the CRS-R.

CONCLUSION

Learning data seemed reconcilable with neurophysiological measures and more positive than CRS-R scores.

Neuropsychological Assessment and Management of People in States of Impaired Consciousness: An Overview of Some Recent Studies

This article is concerned with patients in coma, the vegetative, or minimally conscious states. Studies addressing the issue of assessment and management of these patients are described. These include (a) the development of an assessment tool (Wessex Head Injury Matrix, WHIM); (b) use of the WHIM to assess the effects of posture on arousal, showing that some 75% of patients show more behaviours when assessed while they are in a standing frame than when supine; (c) a comparison of the WHIM with the Glasgow Coma Scale, demonstrating that the WHIM is more sensitive than the GCS for measuring the behavioural repertoire of people in states of reduced consciousness; (d) a discussion of situations when neuro-imaging techniques are required to assess residual functioning; and (e) the long term outcome of one of the first vegetative patients to be scanned with Positron Emission Tomography (PET). We conclude with a discussion about neuropsychology and patients in states of impaired consciousness.

Visual cognition in disorders of consciousness: from V1 to top-down attention

What is it like to be at the lower boundaries of consciousness? Disorders of consciousness such as coma, the vegetative state, and the minimally conscious state are among the most mysterious and least understood conditions of the human brain. Particularly complicated is the assessment of residual cognitive functioning and awareness for diagnostic, rehabilitative, legal, and ethical purposes. In this article, we present a novel functional magnetic resonance imaging exploration of visual cognition in a patient with a severe disorder of consciousness. This battery of tests, first developed in healthy volunteers, assesses increasingly complex transformations of visual information along a known caudal to rostral gradient from occipital to temporal cortex. In the first five levels, the battery assesses (passive) processing of light, color, motion, coherent shapes, and object categories (i.e., faces, houses). At the final level, the battery assesses the ability to voluntarily deploy visual attention in order to focus on one of two competing stimuli. In the patient, this approach revealed appropriate brain activations, undistinguishable from those seen in healthy and aware volunteers. In addition, the ability of the patient to focus one of two competing stimuli, and switch between them on command, also suggests that he retained the ability to access, to some degree, his own visual representations.

Cognition in the vegetative state

Awake but not aware: This puzzling dissociation of the two central elements of consciousness defines the vegetative state. Traditionally, this condition has been believed to imply a brain with preserved hypothalamic and brainstem autonomic functions but with no capacity for cortical cognitive processes. As is discussed in this review, over a 20-year span neuroimaging techniques have clearly demonstrated that this characterization of patients in a vegetative state is incorrect. Contrary to the initial belief, the "vegetative" brain can retain several high-level aspects of cognitive functions, across sensory modalities, including language processing and learning dynamics. Nonetheless, the residual cognitive functions observed in vegetative patients might reflect intact but functionally disconnected cortical modules that do not give rise to the subjective feeling of phenomenological awareness.

Does an early onset and continuous chain of rehabilitation improve the long-term functional outcome of patients with severe traumatic brain injury?

There are currently no international guidelines regarding treatment in the early rehabilitation phase for persons with severe traumatic brain injury (TBI), and only a few studies have investigated the effect of integrating rehabilitation into acute TBI care. The aim of the study was to evaluate whether a continuous chain of rehabilitation that begins with the acute phase could improve the functional outcome of severe TBI patients, compared to a broken chain of rehabilitation that starts in the sub-acute phase of TBI. A total of 61 surviving patients with severe TBI were included in a quasi-experimental study conducted at the Level I trauma center in Eastern Norway. In the study, 31 patients were in the early rehabilitation group (Group A) and 30 patients were in the delayed rehabilitation group (Group B). The functional outcomes were assessed 12 months post-injury with the Glasgow Outcome Scale Extended (GOSE) and the Disability Rating Scale (DRS). A favorable outcome (GOSE 6-8) occurred in 71% of the patients from Group A versus 37% in Group B (p=0.007). The DRS score was significantly better in Group A (p=0.03). The ordinal logistic regression analysis was used to quantify the relationship between the type of rehabilitation chain and the GOSE. A better GOSE outcome was found in patients from Group A (unadjusted OR 3.25 and adjusted OR 2.78, respectively). These results support the hypothesis that better functional outcome occurs in patients who receive early onset and a continuous chain of rehabilitation.

Opportunity for inpatient brain injury rehabilitation for persons in a vegetative state: survey of Swedish physicians

OBJECTIVE

: The aim of this study was to document physicians' opinions on inpatient rehabilitation care for working-age patients in vegetative state after new acquired brain injury, given the absence of an established standard of post-acute care.

DESIGN

: A postal survey of 3259 Swedish physicians was conducted.

RESULTS

: Survey response rate was 33%. Of survey respondents, 51% reported that they knew the definition of vegetative state. Transfer of vegetative patients from acute care to inpatient rehabilitation was considered always warranted by 54% and never or only sometimes warranted by 31% of survey respondents, whereas 15% did not know or did not answer. Rehabilitation physicians most often considered an inpatient rehabilitation stay of around 3 mos to be appropriate, but there was a lack of consensus. Discharge from acute care direct to social care at least sometimes was reported by 39% of physicians.

CONCLUSIONS

: Physicians' opinions vary considerably on appropriate post-acute care for patients in vegetative state after acquired brain injury. This may impact on rates of referral and admission to rehabilitation units. Consensus is needed on a minimum period for and extent of rehabilitation interventions. Educational interventions should be targeted broadly to reach the wide range of specialties that may have responsibility for acute care of these patients.

Post-coma persons with extensive multiple disabilities use microswitch technology to access selected stimulus events or operate a radio device

The present two studies extended research evidence on the use of microswitch technology by post-coma persons with multiple disabilities. Specifically, Study I examined whether three adults with a diagnosis of minimally conscious state and multiple disabilities could use microswitches as tools to access brief, selected stimulus events. Study II assessed whether an adult, who had emerged from a minimally conscious state but was affected by multiple disabilities, could manage the use of a radio device via a microswitch-aided program. Results showed that the participants of Study I had a significant increase of microswitch responding during the intervention phases. The participant of Study II learned to change radio stations and seemed to spend different amounts of session time on the different stations available (suggesting preferences among the programs characterizing them). The importance of microswitch technology for assisting post-coma persons with multiple disabilities to positively engage with their environment was discussed.

An overview of intervention options for promoting adaptive behavior of persons with acquired brain injury and minimally conscious state

This paper presents an overview of the studies directed at helping post-coma persons with minimally conscious state improve their adaptive behavior. Twenty-one studies were identified for the 2000-2010 period (i.e., a period in which an intense debate has occurred about diagnostic, rehabilitative, prognostic, and ethical issues concerning people with severe acquired brain injury). Three of the 21 studies involved transcortical magnetic or deep brain stimulation. Six studies focused on the provision of multisensory stimulation or music therapy. The remaining 12 studies involved the use of response-related (contingent) stimulation and assistive technology. The outcomes of the studies, which were generally reported as positive, were discussed in terms of (a) the size (quantitative relevance) of the changes obtained, (b) the credibility/reliability of the changes, in light of the methodological conditions of the studies, and (c) the level of engagement and interaction involvement of the participants. Relevant issues for future research were also examined.

Persons with Acquired Brain Injury and Multiple Disabilities Access Stimulation Independently through Microswitch-Based Technology

The possibility of enabling two adults with acquired brain injury and profound multiple disabilities to use microswitch-based technology to attain preferred environmental stimuli on their own was assessed. Each of the participants was provided with two microswitches that could be activated by right and left head-turning or head-bending responses. The microswitches were introduced sequentially according to a multiple probe design across microswitches (responses) and allowed access to different sets of auditory or visual stimuli. Eventually, the two microswitches were made available simultaneously. Sessions lasted 5 min. Each participant learned to use the two microswitches successfully and maintained consistent levels of responding when they were simultaneously available. During this phase, both participants showed large within-session variations in their right and left response frequencies, with one of them showing an overall prevalence of the left-side response. The importance of assistive technology within programs for persons with acquired brain injury and multiple disabilities is discussed.

A technology-based programme to help a post-coma man with profound multiple disabilities manage stimulation access and posture improvement

OBJECTIVE

To evaluate a technology-based programme to help a post-coma man with multiple disabilities access stimulation and control head posture (i.e. reduce head forward tilting).

METHOD

The response targeted within the programme was closing the sweater's zipper. This response (which could be repeated since the zipper tended to reopen automatically) was selected, as it led the man to raise his head spontaneously. The programme relied on microswitch sensors to monitor the response and turn on preferred stimuli following response occurrences. The programme was assessed via an ABAB design.

RESULTS

Data showed that the man had significant increases in response frequencies during the intervention phases of the study with multiple occasions of stimulation access and head raising.

CONCLUSION

Technology-assisted programmes may represent a useful strategy for providing post-coma persons with multiple disabilities an active (self-control) role.

Helping a Man With Acquired Brain Injury and Multiple Disabilities Manage Television Use Via Assistive Technology

This single case study was an effort to assess a technology-based program aimed at promoting independent television use by a man with acquired brain injury and multiple disabilities. The technology’s main components were: (a) two microswitches, which allowed the man to request and confirm/trigger with small responses basic television operations (i.e., switching the television on or off and changing channels), and (b) an electronic control unit with an amplified MP3 player, which helped the man with verbal instructions and the execution of the television operations. Results showed that the technology-based program succeeded in enabling the man to manage television use independently. Different amounts of time dedicated to various television programs suggested that the man had different levels of interest for them and could choose among them.

Behavior in the Brain

Recent evidence has suggested that functional neuroimaging may play a crucial role in assessing residual cognition and awareness in brain injury survivors. In particular, brain insults that compromise the patient’s ability to produce motor output may render standard clinical testing ineffective. Indeed, if patients were aware but unable to signal so via motor behavior, they would be impossible to distinguish, at the bedside, from vegetative patients. Considering the alarming rate with which minimally conscious patients are misdiagnosed as vegetative, and the severe medical, legal, and ethical implications of such decisions, novel tools are urgently required to complement current clinical-assessment protocols. Functional neuroimaging may be particularly suited to this aim by providing a window on brain function without requiring patients to produce any motor output. Specifically, the possibility of detecting signs of willful behavior by directly observing brain activity (i.e., “brain behavior”), rather than motoric output, allows this approach to reach beyond what is observable at the bedside with standard clinical assessments. In addition, several neuroimaging studies have already highlighted neuroimaging protocols that can distinguish automatic brain responses from willful brain activity, making it possible to employ willful brain activations as an index of awareness. Certainly, neuroimaging in patient populations faces some theoretical and experimental difficulties, but willful, task-dependent, brain activation may be the only way to discriminate the conscious, but immobile, patient from the unconscious one.

Microswitch- and VOCA-assisted programs for two post-coma persons with minimally conscious state and pervasive motor disabilities

Intervention programs, based on learning principles and assistive technology, were assessed in two studies with two post-coma men with minimally conscious state and pervasive motor disabilities. Study I assessed a program that included (a) an optic microswitch, activated via double blinking, which allowed a man direct access to brief music intervals, and (b) a voice output communication aid (VOCA) with two channels, activated via different hand-closure movements, which allowed the man to call his mother and a research assistant who provided stimulation events. Study II assessed a program that included (a) a pressure microswitch, activated via head movements, which allowed a man direct access to video-clips and music, and (b) a VOCA device, activated via prolonged eyelid closure, which allowed the man to call the caregiver (i.e., a research assistant) who provided attention and sung to him. Each of the two participants had significant increases in both microswitch- and VOCA-related responses during the intervention phases of the studies. Moreover, purposeful choice seemed to occur between the two VOCA responses in Study I. Implications of the findings for improving the situation of post-coma persons with minimally conscious state and pervasive motor disabilities are discussed.

Is there anybody in there? Detecting awareness in disorders of consciousness

The bedside detection of awareness in disorders of consciousness (DOC) caused by acquired brain injury is not an easy task. For this reason, differential diagnosis using neuroimaging and electrophysiological tools in search for objective markers of consciousness is being employed. However, such tools cannot be considered as diagnostic per se, but as assistants to the clinical evaluation, which, at present, remains the gold standard. Regarding therapeutic management in DOC, no evidence-based recommendations can be made in favor of a specific treatment. The present review summarizes clinical and paraclinical studies that have been conducted with neuroimaging and electrophysiological techniques in search of residual awareness in DOC. We discuss the medical, scientific and ethical implications that derive from these studies and we argue that, in the future, the role of neuroimaging and electrophysiology will be important not only for the diagnosis and prognosis of DOC but also in establishing communication with these challenging patients.